Case: Massive hepatic cancer excision and blood transfusion

Poppy, a really sweet little 15kg cocker spaniel, came to us for a cruciate ligament rupture, but all that got put on hold because we spotted that she had a large mass in her abdomen, lurking under the rib cage. This was scanned by Roger and she had a massive liver cancer obliterating half of her liver (both the left lobes). We could not detect any spread. The size of this thing suggested two things –

If it had got this big without spreading, it was unlikely to be majorly aggressive, though it might still very well have malignant potential.

If it was left, it was probably just a matter of weeks before it became a major clinical problem, and/or split with leading to severe and life-threatening hemorrhage into the body cavity.

An attempt at removal, albeit with the understanding that it might be impossible to remove it all, seemed the only way forwards.

We typed her blood and unfortunately the Pet Blood Bank could not supply her blood type (DEA 1.1-ve). She had never had a blood transfusion before, which meant that we could have a large dog (DEA 1.1+ve) on standby in the clinic knowing that if there was a need for an emergency transfusion, we could give a one-time-only transfusion of un-cross-matched blood.

We checked her clotting profile. Clotting times were marginally increased. This was not likely to be a clinical concern, but we felt it prudent to give her an infusion of plasma (this comes as a fresh frozen plasma from the pet blood bank and we kept it frozen til just before surgery, when it was thawed out in a bowl of luke-warm water.

With a team of two nurses to manage the anaesthetic and the theatre space, and two scrubbed in surgically, the mass was removed surgically and this was not straightforwards.

An L shaped abdominal wound was required for access. The initial plan was to remove the mass with a TA stapler. Unfortunately we needed to use “plan B” of ligating large blood vessels and there was severe hemorrhage intra-operatively. An emergency transfusion was required and a further team of vet and nurses had us a bag of blood, still at body temperature, in a jiffy.

We got her stable, closed the wound and recovered her from GA.

The afternoon required constant intensive nursing care as we juggled giving enough fluid and plasma to keep her blood pressure high enough and her heart rate down, while avoiding overly diluting her diminished stock of red blood cells; we stayed on top of her analgesia; we watched closed for any sign of intra-abdominal bleeding and we watched her carefully for any sign of a transfusion reaction. She was kept hooked up to a multi-parameter monitor in her kennel.

The owner was kept in the loop by phone, and they were teetering around requesting euthanasia but we urged them to tough it out.

That evening she was able to hesitantly get to her feet. She stayed under our care over the weekend. She had regular “free fluid scans” with ultrasound to confirm there was no ongoing bleeding, and her heart/pulse parameters were closely monitored. One day post-op she was on her feet and two days post-op she was “pulling” when taken out to toilet!

If ever there was a dog that played Russian Roulette, it was this one!

 

 

 

 

 

WARNING:   Some of the pictures that follow are pretty gory – please only scroll down if you are not squeamish

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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detail transverse

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The wound, nicely healed up a few weeks post-op